After Flap Reconstruction, Complications More Likely in Women With Higher BMI
As body mass index (BMI) goes up, the risk of complications after flap breast reconstruction (also called autologous reconstruction) also goes up.
The research was published in the March 2024 issue of Plastic and Reconstructive Surgery. Read “Relationship between Body Mass Index and Outcomes in Microvascular Abdominally Based Autologous Breast Reconstruction.”
What is flap breast reconstruction?
Flap reconstruction uses skin, fat, and sometimes muscle from another place on your body to make a breast. The flap of tissue may come from:
the belly
the buttocks
the thighs
the back
under the arms
The flap of tissue is moved from its original location to the chest area and attached using microsurgery.
There are a different types of flap reconstruction procedures. They are classified based on where in the body the tissue flap comes from and how the surgeon attaches the flap.
In this study, the researchers looked at flap reconstruction using tissue from the belly.
How Breastcancer.org talks about obesity
At Breastcancer.org we strive to use sensitive, people-first language when talking about diseases and chronic conditions, including obesity. We follow the recommendations of the Obesity Action Coalition and put the person before the disease. So in this article, we say “people who have obesity” rather than “people considered obese” or “people who are obese.”
How obesity was defined in this study
The researchers used five BMI categories in this study:
BMI 25 or lower: healthy weight
BMI 25.01 to 30: overweight
BMI 30.01 to 35: obese
BMI 35.01 to 40: severely obese
BMI 40 or higher: morbidly obese
But it’s important to know that using BMI to assess weight has a number of problems, including not accounting for differences in racial and ethnic groups, genders, sexes, and ages. Researchers developed the BMI categories using information mainly from non-Hispanic white people.
BMI is now so problematic that the American Medical Association (AMA) adopted a policy saying that BMI is an imperfect way to measure body fat. The policy also said that doctors should use BMI carefully and only along with other measurements, such as body composition, to figure out if someone is overweight.
Why do the study?
A 2023 study found that women were more satisfied with their breasts when they had flap reconstruction.
Still, doctors don’t offer flap reconstruction to everyone. The procedure isn’t recommended for women who:
smoke
have uncontrolled diabetes
have obesity
don’t have enough extra tissue to form a flap
Research has linked obesity to higher rates of complications after flap reconstruction, including:
For this study, the researchers looked at the risk of complications after flap reconstruction surgery by BMI category. The goal was to assess whether there should be a cut-off point for surgeons to use when they are deciding whether to offer flap reconstruction to a woman.
About the study
The study included 365 women who had 545 breasts reconstructed using tissue from their belly area. The women’s BMIs ranged from 18.96 to 57.86; the average BMI was 29.49. Overall:
86 women (23.5%) had a BMI of 25 or lower
132 women (36.1%) had a BMI of 25.01 to 30
92 women (25.2%) had a BMI of 30.01 to 35
38 women (10.5%) had a BMI of 35.01 to 40
17 women (4.7%) had a BMI of more than 40
The women had an average age of 49.
There were no differences between the BMI groups with regard to several factors that can affect reconstruction outcomes, including:
age
whether they smoked
whether they had been diagnosed with diabetes
whether they received chemotherapy
Among the 545 reconstructed breasts, 147 breasts (27%) had a complication after reconstruction surgery. The most common breast complications were:
having to return to the operating room (17.6%)
fat necrosis (8.6%)
breakdown or loss of skin, nipple, or areola at the mastectomy site (mastectomy flap necrosis) (7.2%)
any infection (6.8%)
delayed wound healing (6.4%)
wound breakdown that required another operation (6.2%)
The researchers’ analysis found that rates of certain complications increased as BMI increased. Women with a BMI of 35 or higher had higher rates of:
return to the operating room
wound breakdown requiring an operation
infection requiring intravenous antibiotics
mastectomy flap necrosis
The increase in the rate of complications at higher BMIs was statistically significant, which means that it was likely due to the increase in BMI and not just because of chance.
Additionally, women with a BMI of 30 or higher had higher rates of abdominal complications than women with a BMI of less than 30.
The researchers then calculated that the optimal BMI cutoff to minimize breast complications was 32.7. The optimal BMI cutoff to minimize abdominal complications was 30.
“Our study clarifies the impact of high BMI as a risk factor for adverse outcomes of autologous breast reconstruction," senior author Merisa Piper, MD, of University of California, San Francisco, said in a statement. “It also suggests that, among patients with obesity, losing weight before surgery might lower the risk of complications.”
What this means for you
This study found that women with higher BMIs have higher rates of complications after flap breast reconstruction and suggests that women with a BMI of more than 30 might want to consider losing weight before surgery. Still, there are other factors to consider.
Breastcancer.org Professional Advisory Board member Frank DellaCroce, MD, FACS, founding partner of the Center for Restorative Breast Surgery and St. Charles Surgical Hospital, noted that the idea of an optimal BMI cutoff for offering flap reconstruction needs more context.
“The authors should certainly be commended on their efforts to put a number on the candidate seeking reconstruction to simplify the encounter and the decision algorithm, but the variables are many and those in the obese category typically do quite well with the right approach,” he told Breastcancer.org. “BMI in and of itself has also been reported to be an imperfect measure of a patient’s health status.
“We don’t always have the luxury of time to lose weight or make other lifestyle changes in the face of a newly diagnosed cancer, and it’s well-established that patients with obesity do better overall, and are more satisfied, with natural tissue breast reconstruction than they are with implants,” Dr. DellaCroce continued. “Denying a patient immediate reconstruction with her own tissue, forcing an expander reconstruction, and then withholding natural tissue options until a certain BMI number is hit adds additional surgical procedures, trips to the clinic for expander fills, and potential for infection as drains remain around the expander in the post-operative period. It ultimately limits the potential of the result, increases the cost of care delivery, and puts the patient through added stress in a time of stress.”
Dr. DellaCroce said that a BMI of 32.7 — the authors’ recommended cutoff — is equal to a woman who is five feet, five inches tall and weighs 196 pounds. In his clinic, he has done hundreds of successful flap breast reconstructions on women with this BMI.
To help people visualize results, Dr. DellaCroce sent some photos of women with higher BMIs who had flap reconstruction.
“The woman below was diagnosed with cancer in her left breast. She is 5 feet, 7 inches tall and weighs 220 pounds,” Dr. DellaCroce said. “Her pre-operative BMI was 34.5. By the standards in the paper, she would be categorized as obese, and if a strict cutoff were applied, she would not have been offered bilateral nipple-sparing mastectomy and immediate DIEP flap breast reconstruction.”
This woman had a BMI of 34.5 and had nipple-sparing bilateral mastectomy with immediate DIEP flap reconstruction.
This woman had a BMI of 33 and had bilateral mastectomy with immediate DIEP flap reconstruction.
This woman had a BMI of 37.4 and had bilateral delayed DIEP flap reconstruction.
This woman had a BMI of 38.6 and had bilateral mastectomy and immediate DIEP flap reconstruction.
Dr. DellaCroce also noted that the surgical team can make changes to give a woman with a higher BMI the best chance of a successful reconstruction outcome. Strategies include:
changing the incision design in the abdomen to reduce tension, facilitate healing, and limit the time that surgical drains need to stay in
limiting the time that the woman is under anesthesia
improving the blood supply to the transplanted flap tissue
enhanced protocols for recovery after surgery that call for improving pain control without opioids and emphasize having the person moving around as soon as possible after surgery
“Sharing the burden for limiting complications with the patient and making thoughtful adjustments to technique can make all the difference,” he said. “It goes without saying that we should absolutely strive to provide the safest care possible, so the overarching theme of the study is well placed. The cautionary tale for clinicians and third-party insurance companies is to avoid using generalizations or mathematical cutoffs to deny care to those who otherwise would do very well and garner great satisfaction from a procedure that takes advantage of excess fat to rebuild their breast.”
Photos courtesy of Dr. Frank DellaCroce, Center for Restorative Breast Surgery
— Last updated on July 18, 2024 at 7:46 PM
This information made possible in part through the generous support of www.BreastCenter.com.